Innovation Versus Good Solid Medicine
Vol 21 No 6
There is a lot to be said for technological innovation. Without technology we would not have the CT scan, the MRI, and the fancy lab results. We would not have the EKG, the pulse oximeter, or maybe even the sphygmomanometer (blood pressure cuff) and stethoscope. These technology tools are wonderful and fabulous, but one must remember they are only tools! Even the most sophisticated tool cannot replace what you find with your eyes, hands, and ears. Good patient assessment is the key to solid and sound medicine and yet it is one of the skills that are often neglected, especially in medical schools.
In pre-hospital medicine, we often do not have all of the "bells and whistles" that may be possible in the high tech arena. These tools can be valuable under the right applications but one must never, I repeat NEVER, allow these to become anything more than tools to assist in the work. They are never to be the end-all of any examination or diagnosis. As with any component in a good patient assessment, the tools (and even single components of the physical assessment as well) are only individual pieces of the puzzle and one can never see the whole picture without all the pieces. Individual parts should never judge the patient as a whole.
Really, how much do you actually need much of this technology? Let's start from the simple and move to the complex. What does the blood pressure cuff tell you? Be honest. It gives you a set of numbers that tell you absolutely nothing about the patient's overall perfusion status. It's just a set of numbers to compare other numbers to. "Why?" you ask. It is simply because you have no idea what the patient's normal blood pressure is supposed to be. 120/80 tells you nothing. Suppose the patient has a history of hypertension, had a blood pressure of 240/160 before going to his doctor for treatment, and being on his hypertension medication his normal pressure now is 160/100 and his doctor is elated! What does that do to your 120/80 with a patient that is pale, cool, and diaphoretic with a diminished mental status?
What about the pulse oximeter? How much does this really tell you about the patient's overall oxygenation? Let's just say that the pulse oximeter reads 95-100% saturation. Pretty good huh? Yet my patient is having severe difficulty breathing and shows signs of hypoxia. What does the pulse oximeter tell me when my patient is in this state, and yet "fully saturated"? That's right, it tells me nothing about my patient's oxygen status. There are several scenarios, not including "machine error" that may explain this happening. Carbon monoxide poisoning and cyanide poisoning are two explanations. CO binds with the hemoglobin and commits all of the space on the red blood cell and Cyanide poisoning cases have trouble 'offloading' the oxygen at the cellular level. Yet both will read 95-100% on the pulse-ox. The CTC (Cyanide Treatment Coalition, http://www.cyanidepoisoning.org/, see: IFW May/June 2006) has recently presented the most convincing research on cyanide poisoning in smoke inhalation victims and this, as well as CO, can lead to full saturation readings with the pulse oximeter. So why do I occasionally find providers and first responders using the pulse-ox and the EKG when the patient is cyanotic when they do not have oxygen running to their patient? They are relying on the technology to 'TELL THEM' what is going on instead of looking at the patient.
What about the EKG? If I have a patient with an irregular pulse with a rate of 150, what else do I need to know? Well, I want to know his mental status, his skin condition, his chief complaint, how is he breathing, and his medical history. Do I really need the EKG to tell that he is in Atrial-fibrillation? An irregular pulse with a rate of 150 guarantees A-Fib, so why do I need the monitor? Aren't the other issues regarding this patient more important than the monitor? Remember, some patients (maybe not those with a rate of 150, >100 = uncontrolled A-Fib) may have an irregular pulse that is normal for them and they take medication to control that rate. Do not be surprised to find that for these patients this irregularity has nothing to do with their current problems or complaints; the rate greater than 100 may be a compensation for other issues, maybe shock. Not all patients, merely because they have an irregular pulse, are cardiac cases by definition.
So why am I bashing all of the technology that has taken EMS into the 21st century? I'm really not, just pushing the issue that the technology needs to utilized in the manner that it was designed for and that nothing can take the place of your excellent patient assessment skills. The tools that have been given to us as providers are simply that, tools to expand, confirm, and verify what I already know about a patient. The rate and location of the pulse, the condition of the skin, and his mentation tell me vastly more about a patient's perfusion status than any blood pressure reading will do. Complaints of shortness of breath, cyanosis or pallor warrant oxygen administration regardless of what the pulse oximeter might read. GIVE the oxygen! No one EVER died from oxygen, they died from other causes and I don't care what the pulse-ox says. As far as the cardiac monitor, I hope you are using this appropriately as well. Yes, for complex cardiac cases when treating dysrhythmia, the monitor is a valuable and necessary asset. For cardiac arrest, the monitor will confirm V-Fib (or rapid V-Tach) and then we can defibrillate. An AED should suffice for most providers. As you should already know the patient is pulseless and non breathing before you even pick up the monitor or defibrillator because you did the initial assessment!
Make sure your assessment skills are honed like a fine blade. Become a good historian and listener. If you ask the right questions to your medical patients, I promise you, they will TELL YOU what is wrong with them in one way or another. Physical assessment and history should be paramount in your skill repertoire. Practice them like they are the only skills you possess and your patents will benefit from your abilities.